A PRESENTATION BY Kirsteen MacLean Information Services Unit IBIS (Integrated Business Information System)

2 Background

•Corporate Database Project •Planning Model • Population • Need • Demand • Response • Performance

3 Lothian Health

One of largest Health Boards in Scotland Population 772,000 Visiting population of 2.5 million

4 The Information & Statistics Division (ISD) Scotland

Principle Functions : •Collect, collate & maintain NHS datasets •Provide information & statistical services to NHSiS •Provide interpretation & statistical advice

5 Project Objectives

• To develop an easily accessible database • To suit needs of managers & planners • To review information needs • To establish availability of data • To identify information gaps • To improve data definitions • To identify data sharing opportunities • To identify training requirements

6 Project specifications

• Population • Need • Demand • Response & Performance • National & Local Priorities • Key Performance Indicators • NHSiS Corporate Report

7 Prototype Database

8 Interim Solution

9 Advantages of web-based system

• Ease of use • Accessibility • Availability • Straight-forward development • Compatibility

10 Next steps

Pilot application provided by Edina Software ltd The Mortality Indicator using SAS IntrNet

11 Mortality Indicator

Time constraints allowed only one indicator to be developed. SAS IntrNet allows the data to be interrogated on-the-fly. SAS IntrNet ensures the source data is kept secure. SAS IntrNet presents the end-user with useable information. SAS IntrNet allows users to perform on-line queries.

12 The Launch

September 1999 - to 60 key information users.

December 1999 - to all Lothian Health employees.

13 Further Development

Data and information based on the following :

•“Towards a Healthier Scotland” •Social Justice

14 Phase Two

•Terminations •Pregnancies •Low birth-weight babies •Ischaemic Heart Disease •Stroke •Cancer Registrations & Deaths

15 Ischaemic Heart Disease

16 Future Developments

Social Justice Targets Community Planning Milestones Healthy Respect Milestones Health Improvement Programme Targets Population Indicators Corporate Objective monitoring Activity & Finance Report Chief Area Medical Officer (CAMO) 2000 Annual Report

17 Development Work

DA T A W ARE H O USE

Hospital Datasets: Inpatient Outpatient M e n t al H e al t h Pregnancy/B irth B R M E O T GRO(s) Data : A W population estimates SA S births D Web S A Intr/Net deaths T E A Server Server R

Geographical: Data locations - G P P r ac t ic e Hospital Health C entre Pharmacy etc. map data area information boundaries

18 19 The Development of Lothian Health's Integrated Business Information System (IBIS)

Author: Kirsteen MacLean Organisation: Lothian Health

Abstract Following the changes to Health Boards brought about by the White Papers "Designed to Care" and "Working Together for a Healthier Scotland" greater emphasis is placed on benchmarking and performance indicators in the NHS.

In this context Lothian Health proposed a project to identify data available within the NHS and assess methods of analysing and presenting this in new ways to meet the changing role of the Board. The objective was to develop an easily accessible database for Health Service strategic planning, structured to meet the needs of managers and planners.

It was decided to incorporate the database within the Intranet being developed internally using Active Intranet! software thus utilising the web technology available through SAS IntrNet!. This would allow for SAS" processing to happen dynamically in the background without the end user being aware of what package is being used or having access to the original data stored within SAS".

The purpose of this paper is to give an outline into how the Integrated Business Information System (IBIS) was developed from concept to prototype database to an integral part of the Board's Information System and its envisaged development.

Background The publication of the White Papers 'Designed to Care' and 'Towards a Healthier Scotland' brought about major changes to the NHS in Scotland (NHSiS). The papers heralded the end of the internal market and a major change in the role of Health Boards, with greater emphasis being put on the strategic planning role.

The principal role of Health Boards' is mainly focused on improving the health of their population. Working together with Trusts and General Practitioners (GPs) Health Boards are to provide patients with effective and efficient care. To this aim Health Boards, Trusts, GPs and other involved agencies are collaborating in the production of a Health Improvement Plan (HIP) for the resident population in each Health Board area. There is an emphasis on showing that health services are provided both effectively and efficiently. Since the abolition of the internal market, benchmarking and performance measures will have a key role to play in this process.

The Corporate Data Project originated from the new legislation; when the General Manager (now known as the Chief Executive) of Lothian Health proposed a pilot project to assess the changing information needs of the Board. The project was intended to identify data already available within the NHSiS and to assess analysis methods and the presentation of the available data in new ways to meet the changing role of the Health Boards. The project is seen as developing a database that would not only be of use within Lothian Health but could be rolled out to other Health Boards in Scotland to use.

In August 1998 the Corporate Data Project was established as a collaboration between Lothian Health and the Information and Statistics Division (ISD), funded and supported by the Management Executive (ME), with the Project Manager being seconded from ISD to work with Lothian Health staff.

It was agreed that there was a considerable amount of data available within the Health Board, especially in relation to the Acute side of healthcare, for example hospital admissions, outpatient attendances. However this was neither held nor structured in a way that was easily accessible to the management of the organisation.

A suitable structure for the Corporate Database emerged from work already undertaken within Lothian Health; this was based on a planning model developed by the General Manager of Lothian Health.

Population Need Demand Response Performance

The elements of the model are detailed below:

# Population looks at the demographics of the area # Need identifies the potential who, what, where and when # Demand looks at what is required # Response looks at what is delivered # Performance looks at how well the service has met the need.

Suitable datasets to populate these areas had already been identified by work previously undertaken within Lothian Health.

Corporate Database Project The Corporate Database Project was a collaboration between two partners Lothian Health and Information Statistics Division (ISD) Scotland. The project was designed to transform the conceptual model into a user-friendly application available to all staff in Lothian Health. A brief outline of the partners is detailed below:

Lothian Health Lothian health is one of the largest Health Boards in Scotland, covering an area of some 700 square miles with a population of 772,000, and with an estimated visiting population of 2.5 million people whose 'bed nights'iii equate to an additional 20,000 residents throughout the year. There are three Trusts in the Health Board area, these are:

# Lothian University NHS Trust including the major teaching hospital Edinburgh Royal Infirmary which is currently undergoing major redevelopment to a green-field site on the outskirts of Edinburgh.

# Lothian Primary Care Trust

# West Lothian NHS Trust - the only integrated mix of acute and primary care Trust in Scotland.

The Information and Statistics Division (ISD) Scotland The Information and Statistics Division (ISD) Scotland is part of the Common Services Agency for the NHSiS. ISD Scotland has three principal functions:

# To collect, collate and maintain a wide range of National Health Service data sets. # To provide information and statistical services to the NHSiS, other public sector organisations, members of the public and commercial organisations. # To compliment these services with interpretation and statistical advice.

The mission statement of the organisation is 'To contribute to health improvement by informed decision making and stimulating research and debate within the NHSiS, Government Departments and other appropriate organisations.'

Project Objectives & Specification The objectives and specification have formed a major part of the project and much time was spent in ensuring that they met the envisaged criteria. These are outlined below:

Project Objectives The objectives of the Project were agreed as: - To develop an easily accessible database, structured to suit the needs of managers and planners.

# To review all the information needed by Lothian Health to monitor and measure their health improvement objectives. # To establish the availability and format of both national and local information. # To identify any information gaps and where possible give possible short- term solutions. # To improve data definitions. # To identify where opportunities could arise for sharing data and information with appropriate partners. # To identify appropriate end-user tools to ensure ease of access to the data. # To allow access by different staff groups. # To identify any training requirements surrounding the interpretation and use of information within Lothian Health.

Project Specification From the original planning model developed by the General Manager of Lothian Health the following definitions were agreed:

# Population: including the demographic structure of Lothian

# Need: the healthcare needs of Lothian's resident population

# Demand: the usage of healthcare provision within Lothian

# Response & Performance: the response and performance of the NHSiS to the healthcare needs of Lothian's resident population.

To this core were added another three areas:

# National & Local Priorities: national priorities as defined in the Planning & Priorities Guidance for the NHSiS, these are: Coronary Heart Disease & Stroke Cancer Mental Health Care of the Elderly Child Health

The local priorities are defined in the Lothian Health Improvement Programme (HIP), these are: HIV and AIDS Sexual Health in Young People Orthopaedics Diabetics

# Key Performance Indicators (KPIs): as defined by the Benchmarking and Performance Measurement Group established by the Management Executive (ME) in the NHSiS.

# NHSiS Corporate Report: quarterly reports which give information on the performance within Health Boards in relation to national priorities and strategic aims for the NHSiS (e.g. reducing inequalities).

This specification formed the basis for the development of the Prototype Corporate Database using Microsoft" Access98" as the software solution. The main reasons for this decision were:

# At the time there was another project well underway within Lothian Health's Finance Directorate to develop a Single Database and there were hopes to link this database with the Corporate Database. # Lothian Health's Intranet site was under development and Access98" software is web-enabled. # Appropriate skills were available within ISD to develop the Prototype Database and these skills could be transferred to Lothian Health staff without large-scale investment costs.

Prior to any building work being started the levels and format of analyses available to the end-user had to be established, and are summarised below:

# Select indicator # Graph of requested data # Options available for drill-down # Analyses by Deprivation Category # Analyses by Local Government District # Analyses comparison with other like Health Boards and Scotland # Further options within the above to # Analyse by age & sex # Other options # View table # Print # Export table to excel # Export table or graph to Word # Help text

Timescales The proposed timescale for the completion of the prototype was April 1999, after which the database would be handed over to Lothian Health's Information Services Unit (ISU) to develop and maintain. The project agreed that at the time of handover to Lothian Health the following deliverables were to be:

# A report examining the healthcare objectives of Lothian Health and identifying the information available to monitor these, outlining future plans and recommendations. # A prototype database in Microsoft" Access97" accessible by key staff. # A final report on the project giving the database specification and Information Technology (IT) solutions to make the data more accessible with options to the way forward.

Handover to Lothian Health In May 1999 the agreed prototype database was handed over to Lothian Health by ISD, this had been developed using Microsoft" Access97". Although ISU staff had received some basic training in the use of the prototype database from ISD, there were very limited Access97" skills within the department. Figure 1 shows the front screen of the Prototype Corporate Database whilst

Figure 2 gives examples of how the prototype looked on screen.

Figure 1 Front Page of the Prototype Database. (1) Figure 2 Inside the Prototype Database. (2)

Assessment of the Prototype ISU carried out a detailed assessment of the database and considered that further development within Access97" would prove difficult and inappropriate, this was due to a number of problems:

# Lack of Access97" skills in the department. # Access97" would allow insufficient data storage space. # Limited timescales for the acquisition of new skills. # The NT" network at Lothian Health would make the use of Access97" difficult. # Questionable performance levels attainable from Access" software.

Interim Solution At the time that ISU were considering the future development of the corporate database the Lothian Health Intranet was also under development. The Intranet was being developed using an out-of-the-box solution available from Corporate Network Services ltd.- Active Intranet! software. As an interim solution to the problems posed by the corporate database the prototype database was incorporated into the Intranet. The information held in the Access97" database was exported into Microsoft" Excel" using ODBC protocols. Once in Excel" it was relatively easy to design static web pages and graphs to publish using Active Intranet! software. As the database now belonged to Lothian Health it was felt that it needed its own identity and became IBIS (Integrated Business Information System).

The database had moved from being a pilot desktop application to a web- based information system, which would become available to all Lothian Health employees. The advantages of the web-based system were:

# Ease of use # Accessibility # Availability # Straight-forward development # Compatibility with other Lothian Health applications

A deadline of 30th September 1999 had been set for the launch of the database and incorporating what had already been achieved in the prototype into the developing Intranet seemed the best solution in order to meet this deadline. The main issues of how the database would develop and be maintained had still to be addressed.

Next Steps As ISU already managed its data within SAS" and performed all major analyses using a number of SAS" modules available, it was felt that this made the best use of scarce resources within the department. SAS IntrNet! had already been assessed and was considered as an appropriate vehicle for the development of IBIS, although the necessary skills in the use of SAS IntrNet! were not in place.

Due to the short timescales for the production of IBIS help was sought from outside agencies to build a pilot database. Thus, SAS Institute (Glasgow) and Edina Software Ltd. (Edinburgh), a SAS UK Quality Partner, were invited to discuss our development plans and to submit a costed proposal for a development of one indicator.

The proposal from Edina Software Ltd. of a 'proof-of-concept' SAS" application to be incorporated into IBIS, utilising SAS IntrNet! software and providing a dynamic on-line querying option to the end-user was accepted.

Edina Software Ltd. Proposal (3) Edina Software Ltd's proposal:

'It is proposed that Edina Software implement software within Lothian Health's Intranet environment to support remote execution of SAS" jobs from a WWW browser and develop a pilot application to prove the concept of this approach to end user access to SAS" data. The pilot application will provide a request form that allows the user to perform various interactive analyses of a SAS" dataset. Once developed the application will provide a template for readily implementing similar applications for the analysis of other datasets. The pilot application will be a fully developed application (not a rough prototype). It is intended that it will be used in a live environment against real data. The facilities provided by the application are as follows. # The application will provide facilities for a user to generate summaries of a dataset. These summaries will consist of tables of one or more variables, which will support drill-down to expose the characteristics of a subset of the data displayed in a table at a given level. # The request screen will display static information about the dataset and offer a number of initial selections that the user can make when starting their analysis. Variables in the dataset are either described as classification variables (rows and columns for tables) or analysis variables (cell values within tables). # The request screen will allow the user to choose one drilldown hierarchy from a fixed list (Each hierarchy is an ordered list of classification variables). A hierarchy defines the path by which a user wishes to successively explore detail in the data. An example hierarchy for the analysis of a GP sourced dataset might be Area followed by Fundholder Status followed by Age Band of Patient. Selection of this drilldown hierarchy would result in an initial table with one row representing information about a single area. Clicking on an area name will display a similar table of data for that area with one row of the table showing information about all GPs with a particular fundholder status within the selected area. Clicking on a fundholder status will display a similar table of data for the selected area and fundholder status with each row representing a single patient age band. It is proposed that four drilldown hierarchies be defined for the pilot application. # The request screen will offer a choice of one or more analysis variables, which can be summed from those available in the dataset. These determine the values, which appear in the cells of the tables.'

The Mortality Indicator developed using SAS IntrNet! With datasets supplied by ISU and after the required discussions as to what was required, Edina Software Ltd completed the Mortality section of IBIS in the agreed timescale. The application was embedded into the IBIS section of the Intranet allowing the end-user to build their own query on-line without being aware of the SAS" processing being carried out 'on-the-fly'.

Due to the tight timescale for the work the 'Mortality' application focused on only one of the indicators from the Corporate Database and on a single year and did not look at trend data. However it did offer the opportunity to examine the data in some detail and to view the information in either graphical or tabular format. (See Figure 3)

SAS IntrNet! allowed the Mortality application to present the end-user with presentable and useable information. Although the data warehouse, at this time, was only a concept the Mortality application used SAS IntrNet! to query SAS" datasets, summarised from the source data using SAS" programming, 'on-the-fly'

ISU is very much a reactionary, demand driven service to the staff of Lothian Health. The team often feels unable to play a proactive and dynamic role as the information specialists and educators in the organisation because of the heavy workload the current set-up generates.

Figure 3 Screenshot of 'Mortality' (4)

The aim of enabling information users to perform on-line queries was to allow the end-user to explore the data, giving them a feel for the available data and possible analyses before deciding whether further in-depth analyses was required from the ISU team. In turn, it was hoped that this would decrease the number of adhoc requests made to the department and allow the team to develop a more proactive and visionary role. In addition, allowing staff access to the on-line querying facility enabled the department to canvas views of potential information needs in the organisation and thus the future development of IBIS.

The Mortality indicator was made possible by the use of SAS IntrNet! which allows the data to be interrogated whilst ensuring the source data is kept secure. SAS IntrNet! allowed for the provision of data and the flexibility of layout to be met within the tight timescales.

Launch As the launch of the IBIS database preceded the launch of the Intranet it was decided that IBIS would be launched to about sixty key information users and stakeholders within the organisation. This was achieved ahead of the 30th September 1999 deadline. IBIS is an integral part of the Intranet and so became available to staff throughout the organisation when the Intranet went live in December 1999.

IBIS was given a unique identity, which also acknowledged that ISU are responsible for the database.

Figure 4 The IBIS Title Page

Further Development

The long-term vision for IBIS envisages the web-front end to initiate queries on the large volume datasets held in a data warehouse environment, whether held locally by Lothian Health or nationally by ISD. Uncertainty around the way in which SAS" Version8 will connect to SAS IntrNet! have meant that some IBIS developments have been stalled. Following positive feedback from users it was decided that future development of IBIS would be along the lines of the 'Mortality' application. However, the core skills within ISU were primarily in the use of Base SAS" and so appropriate training was required to allow the team to undertake the development of IBIS with SAS IntrNet!.

To allow for a broad development of SAS IntrNet! skills across the team, it was agreed that on-site training was the preferred option. Another SAS UK Quality Partner, Software Product Services Ltd. (Godalming, Surrey) were invited to provide an on-site course 'Web Development with SAS" Software', this course was provided to the ISU team in February 2000, allowing the team to start work on phase 2 of the IBIS development.

Phase 2 (March- May 2000) The White Paper “Towards a Healthier Scotland” challenges Health Boards to tackle the issue of inequalities in access and take-up rates for health services. As this is now the over-arching strategy for all Health Boards, and as such provides the greatest demand for information, it was decided that this phase should concentrate on the provision of data and information for the Inequalities indicator. In detail the areas for analysis are:

# Terminations # Pregnancies # Low birth-weight babies # Ischaemic Heart Disease # Stroke # Cancer Registrations

In order to provide the end-user with as varied a choice in the analyses as possible the datasets for IBIS have been developed to allow information to be viewed either by single years or as a trend over several years. It is possible to select by age, sex, deprivation category, local government district and in some of the analyses the added option of Local Health Care Co-operative (LHCC) is available. Care has also been taken to ensure that all analyses are only available to the appropriate level to ensure that all the information is statistically significant. The analyses can also be viewed in either tabular or graphical format.

It is hoped that with the increasing diversity of the data, information and analyses made available on-line through IBIS that the number of adhoc requests to the department will decrease significantly, allowing more time to be spent in the development and delivery of IBIS and other on-line solutions.

At present the analyses are available as either numbers or crude rates, a further planned development will be the inclusion of standardised rates, although the team are keen to run some workshops to educate information users prior to this development. It is proposed that the end-user will have the opportunity to view the information geographically with the inclusion of mapping into IBIS. An example screenshot of IBIS development is shown in Figure 5

Ischaemic Heart Disease 1992

Figure 5 Sample of IBIS development Phase 2

Phase 3 (June – December 2000) Indicators to be considered are: -

# Monitoring of performance against Social Justice targets # Monitoring of performance against Community Planning "Milestones" # Monitoring of performance against Healthy Respect "Milestones" # Monitoring of performance against HIP targets # Population indicators # Corporate Objective monitoring # Activity & Finance report

Although the population indicators are already present in IBIS it was agreed that it was an area that could benefit from redesign as well as incorporating the routine updating of data. The other indicators will all be new to IBIS, as indeed some are new to the NHSiS, being part of the new agenda for the NHSiS. These will require development to be carried out in conjunction with colleagues throughout the Health Board and appropriate partners from other non-NHS agencies.

Phase 4 (January – April 2001) This will incorporate the data analyses completed by the department for the Chief Area Medical Officer (CAMO) 2000 Annual Report. This will enable users to access and query the underlying data used in the completion of the report. There will also be the opportunity to view the whole document on the Intranet.

Development Work The ISU team has established a data warehouse to provide the background data for IBIS. The data warehouse was deemed necessary as it enabled the core patient identifiable data to be kept secure. A diagrammatic view of how the IBIS data warehouse fits into the schema of the whole is represented in Figure 6.

DATA WAREHOUSE Hospital Datasets: Inpatient Outpatient Mental Health Pregnancy/Birth

M B E GRO(s) Data: GRO(s) Data T R Population estimates SAS Births A Web O Deaths IntrNet! Server W D Server S A E Geographical Data: T R Locations A - GP Practice Hospital Health Centre Pharmacy etc. Map data Area information Boundaries

Figure 6 The Main Components of IBIS

A data warehouse is a database that contains information that is solely used for analytical purposes. A data warehouse contains data that has been gathered together from a variety of sources and is re-organised within the warehouse to be easily managed. There are several advantages to setting up a data warehouse, the main ones that concerned Lothian Health were:

# To distance the end-user from the patient-identifiable and confidential source data # To provide read-only access to the data by the end-user, thus ensuring the integrity of the data # To provide the end-user with access to a wide variety of up-to-date data # To ensure consistency of data as data used for planning, decision-making will all be from one source # To improve efficiency of data management

In building the data warehouse great care has been taken to ensure that the data are as robust as the source data. The processes have also been fully documented to ensure that tasks are easily transferable between team members.

A data warehouse without adequate metadata is like a filing cabinet stuffed with papers, but without any folders or labels. To enable identification of the data and its location in the warehouse, the team have been extremely careful to ensure adequate metadata.

What is metadata? Metadata is data about data. Metadata records provide information about data in a similar way that library catalogues provide information about books. However metadata allows for a much greater amount of information to be available about the data, information on how it is stored, updated, validated as well as defining its meaning and content.

The data for the IBIS warehouse are extracted from all the relevant data held both within Lothian Health and in the wider NHSiS in a variety of sources including SAS". To ensure that the IBIS warehouse data are as current as the source data SAS" programmes have been written to ensure that whenever the core datasets are updated it automatically follows that the IBIS warehouse data are also updated. This also ensures that the core data are secure.

Suites of SAS" programmes have been written and incorporated into SAS IntrNet! to ensure that all permutations of the analyses are available to the end-user. Care has been taken to ensure that the data are robust and that they are never allowed to be drilled-down to such a level that could compromise confidentiality. Care has been taken to ensure that, where required, additional information on the data is incorporated so that the end- user is aware of the source of the data and any necessary caveats. Author Kirsteen MacLean MIS Administrator / Webmaster Information Services Unit Lothian Health Deaconess House 148 The Pleasance Edinburgh EH8 9RS

Tel: +44 131 536 9240 E-mail: [email protected] Website: http://www.lothianhealth.scot.nhs.uk

Acknowledgements SAS Institute Information & Statistics Division (Scotland) Edina Software Ltd Software Product Services ActiveIntranet plc (formerly Corporate Network Services Ltd.) Information Services Unit, Lothian Health

Trademarks All terms mentioned in this paper that are known to be trademarks or service marks have been appropriately capitalised. SAS" and SAS IntrNet! are registered trademarks of SAS Institute. Microsoft" Access97", Microsoft" Access98", Microsoft" Windows NT" and Microsoft" Internet Explorer" are registered trademarks of Microsoft Corporation. Active Intranet! is a registered trademark of ActiveIntranet plc.

References 1. Information Statistics Division, April 1999,Lothian Health's Corporate Database 2. Information Statistics Division, April 1999,Lothian Health's Corporate Database 3. Edina Software Ltd., 19th August 1999, 'Proposal for a Pilot Application' 4. Edina Software Ltd., September 1999, 'Mortality' Application

i ii 'bed-nights' - estimated expected service provision required based on population.